Where There is No Gynecologist

Preventing cervical cancer in low resource settings
By Dina Carlin

"Women are not dying because of diseases we cannot treat...they are dying because societies have yet to make the decision that their lives are worth saving."
-Dr. Mahmoud Fathalla, former president of the International Federation of Gynecology and Obstetrics

In a country where female reproductive health is barely on the agenda, cervical cancer is an example of how modern medicine has stopped short in Mali, largely due to the low availability of resources. Each year there are 500,000 new cases of cervical cancer worldwide, and more than 80% of these cases occur in developing countries (1). According to the World Health Organization, cervical cancer is the most frequent cancer developed in Malian women, with 1,336 new cases each year. Meanwhile, 1,076 cases of cervical cancer in Mali each year result in death. These figures are projected to double in the next 15 years (2). While these statistics are sobering, cervical cancer happens to be one of the most preventable cancers with even infrequent screening. A household condiment, it seems, may be the answer.
The development of cervical cancer, caused by certain strains of the sexually transmitted virus HPV (the Human Papiloma Virus), has been strongly linked to socio-economic status. The increased prevalence of HPV in developing countries, as compared to rates in developed nations, is linked to a comprehensive list of factors, including access to sexual education, age of first sexual intercourse (25% of Malian women have sex before the age of 15), and availability of medical resources. However, the high incidence of cervical cancer is in large due to the lack of access to preventative healthcare. It is estimated that 21.5% of women in West Africa are infected with HPV, and this number has been climbing. In developed countries with fluid, accessible medical technology, the 'Pap' smear, a standard part of a gynecological exam, followed by colposcopy (laboratory analysis of cervical tissue) are well established methods to screen for HPV and precancerous cells. In addition, a vaccine that prevents two strains of HPV most frequently associated with cervical cancer has recently become widely available, albeit expensive. These efforts have led to sharp decreases in cervical cancer worldwide, with the exception of Sub-Saharan Africa. The high cost of these procedures, untrained and inexperienced healthcare providers, and the need for follow-up treatment create obvious barriers for impoverished countries such as Mali.
New procedures for diagnosing cervical cancer have been founded on the need for inexpensive screening methods that require minimal training and single visits to the health center. Since cervical cancer generally develops slowly, screening every 3-5 years, sources say, can have a significant impact in reducing mortality (3). While not as effective as the Pap smear, and certainly not as empirical as cytology, VIA, or visual inspection of the cervix with acetic acid (also known as household vinegar) is a groundbreaking alternative for the developing world. An alternative is VILA, visual inspection with Lugol's iodine, which is a slightly more expensive alternative. It involves only spraying the vinegar or iodine on the cervix, where the precancerous cells turn white in the case of vinegar, or brown with iodine. The simplicity of this procedure involves almost no equipment other than vinegar (widely available in most butigis) or iodine, and can be administered by any health worker.
Treatment for cervical cancer is key, as 95% of cases become fatal within two years. While treatment options vary, one of the cheapest, easiest and quickest treatments for cervical cancer is cytology, which involves "freezing" the cervix using carbon dioxide or nitrogen dioxide, killing off the precancerous cells. Most of the materials are locally available, the training is minimal, and the 15 minute procedure can be carried out by non-clinicians such as Matrons. In addition, it has a very low rate of complications, with cure rates of 85-91% (1).
So what do we do now? Since sustainability is key, working towards training healthcare workers such as Matrones to screen and treat cancer would decrease the impact of this highly destructive cancer. Finally, education and screening initiatives, with the aid of NGOs such as Prevent International Cervical Cancer Now (www.pincc.org) or the Alliance for Cervical Cancer Prevention would help bring the issue of cervical cancer to the national spotlight. Turning to simple and accessible technologies such as VIA and cryotherapy can create the foundation for effective preventative care in reproductive medicine. With all the tools available here in Mali to fight cervical cancer, it is time to decide to take action.


1 Sanghvi H., Lacoste M and McCormick M (eds). (2006). Preventing Cercical Cancer in Low-Resources Settings: From Research to Practice. Report of a conference in Bangkok, Thialand, 4-7 December 2005. JHPIGO: Baltimore, Maryland.
2 WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). (2009). Human Papillomavirus and Related Cancers in Mali: Summary Report 2009. [Accessed October 2, 2009]. Available at www. who. int/ hpvcentre
3 Sankaranarayanan,R.,Budukh, A. M. and Rajkumar, R. (2001). Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bulletin of the World Health Organization. WHO.